While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?
Pitting edema
Capillary refill
Skin temperature
Peripheral pulses
The Correct Answer is A
A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.
B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.
C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.
D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.
B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.
C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.
D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.
Correct Answer is C
Explanation
A. Antidepressant: Antidepressants are not typically associated with a high risk of thrombophlebitis.
B. Antihypertensive: Antihypertensives generally do not increase the risk of thrombophlebitis.
C. Oral contraceptive: Oral contraceptives are known to increase the risk of thrombophlebitis due to their effect on blood clotting factors.
D. Antilipid agent: Antilipid agents, such as statins, do not commonly cause thrombophlebitis.
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